Comparative Guideline Table: Calcium and Vitamin D for Primary

Prevention of Fractures
Rationale: Calcium and vitamin D may prevent fractures, but the magnitude of benefit and potential harms have been controversial.

Issuing
Year
Organization1
U.S. guidelines

Based on
Systematic
Review

Recommendation
Calcium and vitamin D
Population
supplementation dosages

Comments

AAFP

2013

Yes2

None recommended

All adults

Notes insufficient evidence for

primary prevention with
vitamin D3 >400 IU and
calcium >1000 mg/d.
Recommends against lower
doses

USPSTF

2013

Yes

None recommended

All men and

women

Notes insufficient evidence for

vitamin D3 >400 IU and
calcium >1000 mg/d.
Recommends against lower
doses

AACE

2010

Yes

Vitamin D: adequate to maintain

serum levels of 25(OH)D 30-60
ng/mL. Calcium: 1200 mg/d for
postmenopausal women

Adult men and

women

Recommends maintaining
serum levels of vitamin D
primarily through dietary
sources, with supplements if
needed. Cites IOM
recommendations for calcium
intake

NOF

2013

No

Vitamin D: 800-1000 IU/d;

maintain level of 25(OH)D ?30
ng/mL. Calcium: total intake of
1000 mg/d for men aged 50-70;
1200 mg/d for women aged >50
and men aged >70

Adults aged 50
and older

Endorses IOM
recommendations for calcium
intake; suggests supplements
only if inadequate dietary
intake

ACOG

2012

No

Vitamin D: 600 IU/d age 18-70;

800 IU/d age >70; maintain level
of 25(OH)D >20 ng/mL.
Calcium: 1000 mg/d age 19-50;
1200 mg/d age >50

Adult women

Does not directly address

fracture prevention; endorses
IOM recommendations for
calcium and vitamin D. No
recommendation for men

Non-U.S. guidelines
Osteoporosis
Canada

2010

Yes

Vitamin D: 400-1000 IU/d if low

risk for deficiency; 800-1000 IU/d
if moderate risk for deficiency.
Calcium: 1200 mg/d total from
diet and supplements

Adults aged >50

No recommendations made
for adults under age 50

SOGC

2009

Yes

Vitamin D: 800 IU/d

supplementation; Calcium:
1500 mg/d total from diet and
supplements

Postmenopausal
women

No recommendations provided
for men

Gaps in recommendations:

Dietary sources poorly studied; many guidelines do not address younger

women or men.

The ACP Smart Medicine

approach:

Encourage all patients to maintain adequate dietary intake of calcium (1200

mg/d). Provide calcium supplements up to 1200 mg/d in men and women with
inadequate intake; do not routinely provide vitamin D supplements.

ACP Smart Medicine http://smartmedicine.acponline.org.

2014 American College of Physicians www.acponline.org. All rights reserved.
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AACE = American Association of Clinical Endocrinologists; AAFP = American Academy of Family Practice; ACOG = American College of
Obstetricians and Gynecologists; IOM = Institute of Medicine; NOF = National Osteoporosis Foundation; SOGC = Society of Obstetricians and
Gynaecologists of Canada; USPSTF = United States Preventive Service Task Force.
25(OH)D = 25-hydroxy vitamin D; IU = international units.
1

Issuing organization guidelines:

AAFP: Vitamin supplementation. http://www.aafp.org/patient-care/clinical-recommendations/all/vitamin.html
USPSTF: Vitamin D and calcium supplementation to prevent fractures. http://www.uspreventiveservicestaskforce.org/uspstf/uspsvitd.htm
AACE: Watts NB, Bilezikian JP, Camacho PM, Greenspan SL, Harris ST, Hodgson SF, et al. American Association of Clinical endocrinologists
medical guidelines for clinical practice for the diagnosis and treatment of postmenopausal osteoporosis. Endocr Prac. 2010;16 (suppl 3).
https://www.aace.com/files/osteo-guidelines-2010.pdf
ACOG: ACOG Practice Bulletin N. 129. Osteoporosis. Obstet Gynecol. 2012;120:718-34. PMID: 22914492.
http://www.ncbi.nlm.nih.gov/pubmed/?term=22914492
NOF: 2013 Clinicians guide to the prevention and treatment of osteoporosis. http://nof.org/files/nof/public/content/file/917/upload/481.pdf
SOGC: Reid R, Senikas V, Fortier M, Blake J, Abramson B, Khan A. Menopause and osteoporosis update 2009.
http://sogc.org/guidelines/menopause-and-osteoporosis-update-2009-replaces-171-feb-2006-172-feb-2006/
Osteoporosis Canada: Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, et al; Scientific Advisory Council of Osteoporosis
Canada. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010;182:1864-73.
http://www.cmaj.ca/content/early/2010/10/12/cmaj.100771.full.pdf+html

Based on USPSTF systematic review.

Table created on behalf of the SGIM EBM Task Force by:

Julie Rivera Gilbreath, MD, Division of General Internal Medicine, Department of Medicine, University of Texas Health Science Center at San
Antonio; KoKo Aung, MD, MPH, FACP, Division of General Internal Medicine, Department of Medicine, University of Texas Health Science Center at
San Antonio.
Disclosures
Julie Rivera Gilbreath has no financial relationships with any entity producing, marketing, re-selling, or distributing health care goods or services
consumed by, or used on, patients.
KoKo Aung has no financial relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed
by, or used on, patients.

ACP Smart Medicine http://smartmedicine.acponline.org.

2014 American College of Physicians www.acponline.org. All rights reserved.
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